Dementia psychotic symptoms

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Psychotic symptoms in late life (greater than 65 years of age) are generally a result of an ongoing chronic illness carried over from younger life however, a small percentage of patients develop psychotic symptoms de novo, defined as late-life schizophrenia. The 6-month prevalence rate of schizophrenia in the elderly is around 1%. However, other illnesses presenting with psychotic symptoms are common in this population, as approximately one-third of patients with Alzheimer s disease, Parkinson s disease, and vascular dementia experience psychotic symptoms. The majority of data for antipsychotic use in the elderly comes from experience treating these other disease states. 

Frontotemporal dementias are characterized by gross structural changes in the frontal and anterior temporal lobes, metabolic disturbances, and involvement of certain subcortical structures as well (Ishii et al. 1998). Whereas in Alzheimer s disease the early cognitive disturbances are in memory, in frontotemporal dementias the early manifestations are in executive and behavioral function (Pfeffer et al. 1999 Varma et al. 1999). This relative cognitive distinction persists throughout the course of the two disorders (Pachana et al. 1996). Disinhibition and disorganization are common, and psychotic symptoms may be prominent in frontotemporal dementia. 

Psychosis for demented patients usually takes the form of paranoid delusions. Demented patients may believe family members have turned against them, or they may misidentify their loved ones as intruders in their home. Although hallucinations are not listed in the DSM-IV criteria, they may also occur. When psychosis occurs in a demented patient, it is a serious problem. It is very distressful to the patient, makes it difficult (if not impossible) for family members to provide care, may lead to episodes of violence, and commonly leads patients to be hospitalized or placed in nursing homes. Fortunately, most patients with dementia do not develop delusions or other psychotic symptoms. 

In a similar study, Petrie et al. (1982) studied the effectiveness of halo-peridol and loxapine in the same type of patients. The conclusion was that, although the improvement of the psychotic symptomatology was evident, the global improvement of life quality was not that evident. The authors suggested that the medication response in elderly patients with dementia and psychotic symptoms was much inferior to the one observed in young patients with schizophrenia. R. Barnes et al. (1982) carried out a similarly designed study and found an improvement in only one-third of the treated patients. However, that sample was oriented not only to psychotic symptoms (delusions and hallucinations) but also to disruptive behaviors in general. 

Drevets WC, Rubin EH Psychotic symptoms and the longitudinal course of senile dementia of the Alzheimer type. Biol Psychiatry 25 39-48, 1989... 

More recently, 206 nursing home patients with moderate to severe Alzheimer s dementia with behavior disturbances or psychosis were randomly assigned to either placebo or a fixed dose of olanzapine at 5, 10, or 15 mg per day for up to 6 weeks of treatment ( 285). In this multicenter, double-blind, placebo-controlled study, olanzapine was significantly more efficacious than placebo in reducing psychosis and behavioral disturbances. The best result was obtained with the 5-mg dose in patients who did not have delusions or hallucinations. Although these patients were selected because of behavioral disturbance, hallucinations, or delusions, 75% did not have hallucinations at baseline, 43% did not have delusions at baseline, and 38% did not have psychosis at baseline. At end point, of those patients without hallucinations at baseline, hallucinations developed in 7.4% on olanzapine, compared with 21.9% on placebo ( p = 0.045). For those without delusions, 17% of placebo patients and 4% of olanzapine patients experienced delusions. For those subjects without psychosis (i.e., neither hallucinations nor delusions), psychosis developed in 8% of olanzapine patients and 25% of placebo patients (p = 0.006). Thus, olanzapine also seemed to prevent the occurrence of psychotic symptoms as the disease progressed. 

Those disorders that require the presence of psychosis (Table 10—1) as a defining feature of the diagnosis include schizophrenia, substance-induced (i.e., drug-induced) psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder due to a general medical condition. Disorders that may or may not have psychotic symptoms (Table 10—2) as an associated feature include mania and depression as well as several cognitive disorders such as Alzheimer s dementia. 

CNS diseases have been identified with imbalances or the inability to attend to the initial stimuli and correctly process critical stimuli.16 For example, schizophrenia has been proposed to be reflective of a hyperattentive state in which the occurrence of psychotic symptoms may be due to the inability to limit or selectively process critical stimuli versus non-critical stimuli. Conversely, age-related memory decline and progressive dementia as seen in diseases such as Alzheimer s would clearly be associated with a hypoattentive state.16- 85 Whether... 

In a multicenter, randomized, double-blind, 12-week trial in Australia and New Zealand, 384 patients with dementia, mainly Alzheimer s disease, were initially enrolled and received at least one dose of risperidone (n = 167 71% women mean age 83 years modal dose 0.99 mg/day) or placebo (n = 170 72% women mean age 83 years) (47). Clinical improvement in aggression and psychotic symptoms was evidenced by means of specific scales 45 subjects taking risperidone and 56 taking placebo did not complete the trial, mainly because of insufficient responses and adverse effects. In the whole sample there was a high prevalence and variety of adverse events (94% of those taking risperidone and 92% of those taking placebo), mainly injuries, falls, somnolence, and urinary tract infections however, only the last two were more common in those taking risperidone than in those... 

Bergman J, Brettholz I, Shneidman M, Lerner V. Donepezil as add-on treatment of psychotic symptoms in patients with dementia of the Alzheimer s type. Clin Neuropharmacol 2003 26 88-92. 

Agitation, which may occur in patients with dementia, can be treated with anti-psycho tics agents, mood stabilizing anticonvulsants, trazadone and anxiolytics (Doody et al., 2001). The atypical anti-psychotic medications are the treatment of choice for psychotic symptoms, such as hallucinations or delusions, particularly in those with Parkinsonism in whom dopamine receptor blockage is contraindicated due to the potential to worsen motor symptoms. In these patients, clozapine, which may reduce tremor in addition to its anti-psychotic effects, is particularly effective. However, rare cases of agranulocystosis necessitate weekly blood counts, and so limit its utility. Que-tiapine may be the next agent of choice because it appears to have fewer adverse motor effects than the other medications... 

The deterioration of function in dementia of Alzheimer s disease is often accompanied by acute behavioural disturbance and the development of a range of psychotic symptoms. Therapy with atypical drugs is then preferred because they provoke fewer adverse effects than classical antipsychotics. 

Loxapine is used to treat and control the psychotic symptoms of both acute and chronic schizophrenia. Other uses include treatment of dementia, anxiety neurosis, hostile/aggressive behavior, and psychotic depression. 

Until the advent of the atypical antipsychotics, conventional agents were widely used, although available placebo-controlled studies suggested that they were moderately effective at best. More recently, risperidone has been shown to have modest effects in patients with psychotic symptoms or behavioral disturbances associated with dementia. " It is recommended to begin with 0.25 mg daily and to titrate in 0.25- to 0.5-mg increments to 1 mg daily, which is usually considered the optimal dose. If response is inadequate, further titrating to a maximum of 2 mg daily may be necessary if the patient is tolerating the medication however, side effects, particularly extrapyramidal effects, somnolence, and orthostasis, increase with increased dose. 

In another report, a 70-year-old depressed man with no significant medical illness developed auditory and visual hallucinations after 3 days of escitalopram treatment at 5 mg per day, continuing when citalopram was increased to 10 mg per day. Investigations, including cranial MRI were negative, his MMSE score was 23/30 and there was no evidence of either delirium or dementia. Following suspicion of drug-induced psychotic symptoms, escitalopram was tapered to 5 mg per day and ceased after which his psychotic symptoms abated [36 ]. 

Delusions/Psychosis. Demented patients who are acutely psychotic and agitated should be treated in much the same manner as demented patients with delirium. Low doses of a high potency conventional antipsychotic like haloperidol were once preferred. This was mainly because it can be given both orally and by injection. In recent years, the atypical antipsychotic ziprasidone, which is now also available in oral and injectable forms, has superseded haloperidol as the preferred agent when treating the acutely psychotic and agitated patient with dementia. As previously noted, ziprasidone affords the same tranquilizing benefit as haloperidol, it can now be administered via injection when necessary, and it avoids the problematic extrapyramidal symptoms of haloperidol to which patients with dementia are often keenly sensitive. 

Depressive and anxious symptoms are frequently associated with schizophrenia, but this does not necessarily mean that they fulfill the diagnostic criteria for a comorbid anxiety or affective disorder. Nevertheless, depressed mood, anxious mood, guilt, tension, irritability, and worry frequently accompany schizophrenia. These various symptoms are also prominent features of major depressive disorder, psychotic depression, bipolar disorder, schizoaffective disorder, organic dementias, and childhood... 

Some maintain that rather than treating a disease or condition, neuroleptics often create another disease. Although these drugs eliminate or reduce the intensity of psychotic experiences such as delusions and hallucinations, the adverse side effects that may actually worsen the symptoms of dementia. 

Seven elderly patients with psychotic or non-psychotic behavioral symptoms in Lewy body dementia had some benefit from donepezil (24). Donepezil was withdrawn prematurely in three patients owing to poor response and/or adverse events. The adverse events were sedation, somnolence, worsening of chronic obstructive pulmonary disease, syncope, sweating, and bradycardia. These results have to be confirmed in controlled trials. 

Most inhalants or volatile substances are solvents, but the DSM-IV-TR text attributes only five of the eight disorders associated with inhalants to solvents substance-induced psychotic disorder, anxiety disorder, delirium, persisting amnestic disorder, and symptoms of dementia. The association of solvents with dementia is more controversial than their association with mood disorders, but DSM-IV-TR does not recognize mood disorder resulting from solvent exposure. These inconsistencies probably reflect incomplete fidelity between the literature and the psychiatric nosology rather than current opinion. 

Substance-induced psychotic disorder Substance-induced anxiety disorder Substance-induced delirium Substance-induced persisting amnestic disorder Symptoms of dementia... 

Ketamine causes memory deficits reproduces with impressive accuracy the symptoms of schizophrenia is widely abused and induces vacuoles in neurons at moderate concentrations and cell death at higher concentrations. Memantine, on the other hand, is well tolerated although instances of psychotic side effects have been reported, in placebo-controlled chnical studies the incidence of side effects is remarkably low. Memantine improves memory in Alzheimer dementia patients and in some (but not all) studies in animals [1]. 

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